NAME/RANK:

SSN:

DOB:

PRESENT COMMAND:

BR OF SERVICE:

DATE:

(CONCEALMENT OF MEDICAL HISTORY WILL BE REPORTED TO HIGHER AUTHORITIES AND MAY RESULT IN PERMANENT DISQUALIFICATION.)

DIVING MEDICAL QUESTIONS

Yes

No

1.  Have you ever been found medically disqualified for a dive physical or any other physical at any time? 

2.  Since your last physical, or in the last 18 months, have you been sick, injured, consulted a physician, used medication (including over-the-counter), or been hospitalized for any reason?

3.  Have you ever experienced any middle or inner ear dysfunction including inability to equalize middle ear pressure, inner or middle ear surgery, ringing, dysequilibrium, hearing deficit?

4.  Is or has your uncorrected vision ever been worse than 20/20 in either eye?

5.  Do you have any difficulty distinguishing colors or seeing at night?

6.  Have you ever had any corneal surgery, or manipulation to correct poor vision?

7.  Since age 12, have you had asthma or wheezing at any time?

8.  Have you ever had a collapsed lung (pneumothorax), experienced pulmonary barotrauma, had a positive PPD, or taken INH in the past 6 months?

9.  Do you have any skin condition worsened by tight clothing, moisture, or sun exposure?

10.  Do you have any musculoskeletal condition that limits intense exercise, suffered any type of fracture in the last 3 months, or had any bone/joint surgery in the last 6 months?

11.  Have you ever been evaluated for, or treated for, any psychiatric problems (including depression, anxiety, personality disorder, etc.)?

12.  Have you ever had legal, professional or personal problems due to alcohol use, or been diagnosed with dependence, or had any level of treatment for abuse?

13.  Have you ever had a migraine or other severe headache?

14.  Have you ever had seizures, convulsions or sustained a head injury resulting in loss of consciousness, loss of memory, concussion, or skull fracture?

15.  Have you ever had brain surgery?

16.  Do you have any area of altered sensation or strength in your body?

17.  Have you ever suffered Decompression Sickness or Arterial Gas Embolism?

18.  Do you suffer from motion sickness or fear of enclosed spaces?

PATIENT SIGNATURE:

DATE:

DIVER/BUD/S MEDICAL SCREENING QUESTIONNAIRE (Cont'd.)

ANY POSITIVE RESPONSES REQUIRE ELABORATION ON THIS PAGE BY A DIVING MEDICAL OFFICER

NAME/RANK:

SSN:

DOB:

PRESENT COMMAND:

BR OF SERVICE:

DATE:

ADDITIONAL DIVING MEDICAL QUESTIONS

DMO SCREEN (to be filled out by DMO/UMO, HMO or qualified representative)

Yes

No

1.  SF 88, Report of Medical Examination and SF 93, Report of Medical History are complete, correct, for dive/jump duty and within 1 year of application?

2.  Is the physical signed/countersigned by a DMO/UMO or HMO?

3.  Every page of member’s health record has been reviewed?

4.  Any disqualifying condition has a completed, approved waiver from BUMED (Med-21)?

5.  Any non-disqualifying condition that might affect dive training is thoroughly documented?

DIVING MEDICAL OFFICER COMMENTS

QUESTION#

COMMENT

CD/NCD?

WAIVER?

 Yes  No

 Yes  No

DMO SIGNATURE

DMO STAMP

DMO PHONE NUMBER

DMO FAX NUMBER

RECORD SCREENING (to be filled in by medical department)

G6PD results

Sickle cell results

Blood Type

IMMUNIZATION MUST BE COMPLETED AND CURRENT PRIOR TO TRANSFER

  Tetanus

Date

  Typhoid

Date

  Yellow Fever

Date

  HAV

Date

  Flu

Date

ADDITIONAL DIVING MEDICAL QUESTIONS (Cont'd.)

DMO SCREEN (to be filled out by DMO/UMO, HMO or qualified representative)

PPD given with diving medical examination.

 Yes  No        Date       

PPD Converter  YES  NO

PPD Converters must complete INH Tx prior to transfer to diver training.

PPD annual questionnaire required for converters.

Date of last Dive Physical (SF 88/93):       

Dental, must be Class I or II. Last examination date:       

Pressure Test, date completed:       

NAVMED 6150/2, Special Duty Medical Abstract required  with signature from DMO/UMO/HMO stating Physically Qualified for

Diving Duty.

    Completed

 YES

 NO

Visual Acuity: (must correct to 20/20; if not, waiver required)

·         USN Fleet Diver/Basic Diving Officer, USA OOB, EOD:  20/200 or better.  Waiver required if greater

·         Marine Combat Diver:  20/100 better eye, 20/200 worse eye, or better

·         Diving Medical Officer and SCUBA:  + or – 8 Diopters

·         SEAL Candidate:  20/40 in best eye, 20/70 in worst eye (Waiverable to 20/70,20/100.  Waiver must be completed.)

Hearing Standards:

1000 Hz 30 db

2000 Hz 35 db

3000 Hz 45 db

4000 Hz 55 db

If greater, waiver required.

The following labs are complete on SF 88: Serology, CBC with DIFF, Lipid panel HIV, G6PD, Sickle Cell, and Blood Type?

 YES

 NO

SEAL, EOD, USA OOB, and Underwater Construction Diver require Fasting Blood Sugar and Routine Urine. (Appropriate /corresponding lab chits are in the medical record.)

 YES

 NO

The following studies are complete on SF 88: CXR, EKG, Audiogram, PPD, and Falant? (Appropriate/corresponding studies, reports are in the medical record.)

 YES

 NO

MEDICAL SCREENER NAME, RANK/RATE, AND TITLE

PHONE NUMBER:       

FAX NUMBER:       

Command's mailing address

NOTE:  THE DIVER MEDICAL SCREENING QUESTIONNAIRE AND SF 88/93 MUST BE COMPLETLEY FILLED OUT AND FAXED TO NAVY DIVING AND SALVAGE TRAINING CENTER (NAVDIVSALVTRACEN), MEDICAL DEPARTMENT, PANAMA CITY, FL PRIOR TO APPLICATION TO NAVY PERSONNEL COMMAND (NAVPERSCOM) (PERS-401D OR PERS-407CK).  ANY WAIVERS MUST HAVE WRITTEN APPROVAL BY BUREAU OF MEDICINE AND SURGERY (BUMED) (MED-21) AND A COPY FAXED TO NAVDIVSALTRACEN, MEDICAL DEPARTMENT.

TELEPHONE:

DSN 436-5215      COMM (850) 235-5215

MEDICAL FAX:

DSN 436-5993      COMM (850) 235-5993

STUDENT SUPPORT OFFICE FAX:

DSN 436- 5242     COMM (850) 235-5242

NOTE: FOR SEAL CANDIDATES THE MEDICAL SCREENING QUESTIONNAIRE AND SF 88/93 MUST BE COMPLETELY FILLED OUT AND FAXED TO NAVY SPECIAL WARFARE CENTER, BUD/S MEDICAL DEPARTMENT PRIOR TO APPLICATION TO NAVPERSCOM (PERS-401D).  ANY WAIVERS MUST HAVE WRITTEN APPROVAL BY BUMED (MED-21) AND A COPY FAXED TO BUD/S MEDICAL DEPARTMENT.

TELEPHONE:

DSN 577-0777      COMM (619) 437-0777

MEDICAL FAX:

DSN 577-5248      COMM (619) 437-5248

PLACE ORIGINAL DIVER MEDICAL SCREENING QUESTIONNAIRE, SF 88/93, AND ANY APPROVED WAIVERS IN MEDICAL RECORD.

NAVDIVSALVTRACEN HOME PAGE:

www.cnet.navy.mil/ndstc/

NAVY SPECIAL WARFARE CENTER BUD/S HOME PAGE:

www.sealchallenge.navy.mil

DIVING STANDARDS:

NAVMED P-117, Manual of the Medical Department, chapter 15, article 15-66, and section III

BUMEDNOTE 6120 of 30 Jul 97 (canc frp:  Jul 98):

http://www.navymedicine.med.navy.mil/instructions/external/6120-7-30-97.pdf

MEDICAL WAIVER:

NAVMED P-117, article 15-74

BUMED (MED-21) TELEPHONE:

                  COMM (202)762-4342